=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285038935
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLEARWATER IN-HOME CARE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2014
-----------------------------------------------------
Last Update Date | 12/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1525 BUSINESS HIGHWAY 60 SUITE C
-----------------------------------------------------
City | DEXTER
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-614-5886
-----------------------------------------------------
Fax | 573-614-5894
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 859
-----------------------------------------------------
City | DEXTER
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63841-0859
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-614-5886
-----------------------------------------------------
Fax | 573-614-5894
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY/MANAGER
-----------------------------------------------------
Name | MRS. BILLIE JO DELORES CRANE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 573-614-5886
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 385H00000X
-----------------------------------------------------
Taxonomy Name | Respite Care
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3747P1801X
-----------------------------------------------------
Taxonomy Name | Personal Care Attendant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------